The Dynamic and Multisource Nature of Support for Frontline-Led Innovation Teams

Abstract

This 24-month inductive study examined the practices provided by a variety of supporters to six frontline-led innovation teams. Analyzing 86 interviews with 35 team members and 17 supporters, we propose a comprehensive, idealized framework of dynamic and multisource support. These practices offered critical aid as teams dealt with limited innovation experience, limited relationships, and limited contextual awareness. We categorized the practices we identified into six sets—Ensure Foundational Support, Transmit Knowledge and Skills, Nurture Teams and Teamwork, Cultivate Relationships with Decision-Makers, Scaffold Project Work, and Foster a Holistic View of Innovation Work—and discussed their benefits and boundaries of effectiveness. Our framework challenges the notion of “one-size-fits-all” support, emphasizing the value of adaptive support instead. We also highlight the critical role of coaches and identify significant roles unexpectedly played by the funder, insurer, student fellows, and research-observers that provided instruction, resources, and encouragement.

Introduction

Health care organizations increasingly rely on frontline-led innovation teams to improve care delivery and employee morale (Atkinson & Singer, 2021; Jung et al., 2024). Frontline-led innovation teams involve clinicians, staff, and managers who are closest to care delivery and, thus, most aware of improvement opportunities and how they can be implemented well (Jung et al., 2023; Satterstrom et al., 2021). Innovation entails identifying problems and then generating, testing, and implementing solutions, which encompass activities related to process or quality improvement (QI) (Jung & Cummings, 2023). We use the terms innovation and quality or process improvement interchangeably. These bottom-up efforts complement top-down efforts, which are dictated by policy or institutional changes (Stouten et al., 2018). To ensure frontline teams live up to their potential, they need to be properly equipped and supported.

Individuals and groups provide various forms of support to help frontline-led innovation teams deal with numerous barriers (Rushton et al., 2023). We describe anyone providing such support as a “supporter.” Supporters help innovation teams when they are stretched by core tasks, have limited exposure to improvement methodology and mindsets, and work in hierarchies and silos that hinder some team members from fully participating in innovation (Atkinson & Singer, 2021; Jung & Cummings, 2023; Satterstrom et al., 2021). To equip and bolster innovation, organizations have created innovation centers and provided QI training and opportunities to frontline staff, and partnered with federal, state, and local learning collaboratives (Meer et al., 2023). These supporters have engaged in many activities to motivate, facilitate, and sustain innovation teams and their work.

However, less is known about the dynamic and multisource nature of support, particularly who could provide it and when it might be needed. Prior research has described support features that teams found “helpful for advancing their improvement efforts overall and knowledge acquisition,” such as collaborative faculty and learning session interactions (e.g., Nembhard, 2009, p. 359). We build on this work and explore supporter practices that respond to different barriers, who delivers the support, and the benefits and boundaries of these practices, including unintended consequences. Without adequate understanding of how to effectively support innovation teams, support may vary in an unguided way or be provided in a “one-size-fits-all” approach without considering the team’s idiosyncratic context and needs.

In this study, we systematically examined the support practices provided by multiple supporters in response to barriers encountered by frontline-led innovation teams, who provided the support, and how the teams perceived the support. We studied an innovation incubator through which teams interacted with a range of supporters employing a variety of support practices.

Conceptual Framework

Innovation teams require multifaceted support—including resources, motivation, information, task-based knowledge and skills, relationships, structure, and contextual awareness—to function effectively and achieve their goals. Foundational support, such as access to adequate resources, relevant data, and a clearly articulated motivation for engaging in work, is essential for team performance across industries and experience levels (Hackman, 2002). Without such support, even skilled teams may struggle to develop and implement innovations.

The innovation and organizational change literatures have long underscored the interdependence of technical and relational dimensions of work (e.g., Battilana et al., 2010). In the context of innovating health care delivery, research has emphasized the importance of fostering both task and relationship skills in teams by not only leveraging static frameworks but also hands-on coaching (Dixon-Woods et al., 2011; Nembhard, 2009). Innovation teams can use frameworks and methodologies to systematically engage in improvement and innovation tasks—such as identifying the root cause that warrants innovation, generating innovative solutions, implementing validated changes, and scaling and sustaining interventions. The Model for Improvement, developed by the Institute for Healthcare Improvement (IHI), encourages teams to define a clear and specific aim for improvement work, identify measures to track progress and evaluate the impact of the improvement work, and use plan-do-study-act (PDSA) cycles to test, learn, and refine improvement ideas (Langley et al., 2009). Guided innovation communities—including learning and QI collaboratives, incubators, and innovation centers—offer programs to help teams build task-related skills and relationships (Bardach et al., 2024; Cardenas et al., 2023; Nembhard, 2009; Weaver et al., 2015). These communities bring together teams of clinical and administrative staff to enhance problem-solving by combining diverse perspectives on the realities of patient care and workflows, and operational logistics (Atkinson & Singer, 2021; Jung et al., 2024). Nembhard (2009) and other researchers have described features of innovation communities, yet less is known about when and which practices supporters could use across different teams.

Teams—particularly novice teams—also need structures to help scaffold their innovation work (e.g., Cardenas et al., 2023; Weaver et al., 2015). To this end, guided innovation communities often include structured programs that bring together innovation teams from different organizations to address health care challenges (e.g., reduce surgical site infections, improve safety culture) and learn from each other (Bardach et al., 2024; Nembhard, 2009). These communities typically encompass a series of meetings, conference calls, or online discussions, allocating dedicated space and time for innovation, away from day-to-day clinical or administrative responsibilities. Such structures allow full engagement of frontline workers in learning how to innovate and carry out the innovation work. Project management skills or roles that structure the team’s work by creating plans to ensure timely coordination of tasks and updating plans when the situation changes are also key to team-based innovation work (Edmondson & Nembhard, 2009).

While innovation work often involves understanding and addressing a particular problem or opportunity, teams also need to hold a larger strategic view of their work. The success of innovation work depends on the policy and financial landscape, and ongoing changes at the national, state, and community levels that can affect reimbursement and workforce issues (Damschroder et al., 2009). To ensure an innovation is sustainable, teams should know what policy levers can be used to save costs and demonstrate improvement. However, many frontline teams lack such a contextual picture, and teams’ frontline and middle managers may be unable to provide a more holistic view for the team. Teams may benefit from a network of experts and community partners that enable teams to obtain technical expertise and guidance to ensure that innovations are evidence-informed and avoid reinventing the wheel by learning from prior work; receive feedback on feasibility, acceptability, and potential unintended consequences; and attain additional funding for project work as needed.

Bringing together such multifaceted elements of support for innovation teams, we offer a comprehensive, idealized framework for supporting innovation teams that builds on prior research and addresses key gaps in existing models. Our framework offers a robust and holistic perspective that extends beyond process change. The sets of support we describe are dynamic and multisource in nature. Rather than solely examining what individual supporters should do, we emphasize the importance of understanding the broad, idealized system of support for teams. Articulating the idealized sets of support practices can enable teams and organizations to proactively assign supporter roles or cultivate them as needed. Moreover, the comprehensive support framework allows teams to tailor the support to their local context, such as a respective team’s prior experience with innovation and the idiosyncratic barriers they may face in their innovation work.

Given the inductive nature of this study, we did not begin with a reference to a specific theoretical framework. Instead, we induced our conceptual framework from patterns that emerged through iterative analysis of the data. This process led to Figure 1, which we present in the Findings section.

Figure 1.

Idealized Framework of Support Practices for Frontline-Led Innovation Teams.

New Contributions

This study makes several new contributions. First, we provide a comprehensive idealized framework of practices for how supporters responsively engage frontline-led innovation teams from onboarding through developing, implementing, and scaling innovations. Using longitudinal interview and archival data, we develop sets of practices that range from providing financial support, affirming individuals and teams, facilitating skill building via iterative instruction and hands-on support, to contextualizing project work. These sets work together to provide a net of support for teams, especially those who have limited innovation experience, limited relationships within and outside their health care organization, and limited contextual awareness for how to engage with innovation work while completing their day-to-day tasks. Second, our findings show that evidence-based methods and support practices are not “one size fits all.” Rather, innovation team members perceived supporters as most helpful when they were responsive, shifting the pace and focus of their support to teams’ multifaceted and dynamic needs. While some barriers, like limited time, were common, other barriers, like limited innovation experience or relationships, were more idiosyncratic, underscoring the importance of supporters’ understanding of each team’s experience of barriers to innovating. Third, we build on earlier work documenting benefits of coaches for innovation teams (e.g., Dixon-Woods et al., 2011). We highlight multiple, often unexpected, sources of support, including the funder, insurer, student fellows, research-observers, incubator advisory board, and community organizations, all of whom engaged in critical support practices.

Methods

Study Context

We followed six interdisciplinary innovation teams in federally qualified health centers (FQHCs) that participated in a year-long incubator designed to help teams generate and implement innovations to improve patient care while lowering costs. Three teams participated from 2021 to 2022 and three teams participated from 2022 to 2023. Team members included senior leaders, middle managers, and frontline clinicians and staff, such as physicians, nurse practitioners (NPs), nurses, medical assistants (MAs), and call center agents. The incubator provided training, coaches, and data, and a US$150,000 stipend per clinic to offset personnel time to engage with innovation work.

The incubator provided a range of “supporters” that included: experts who offered support based on years of clinical and QI experience (“content coaches”), with two of the content coaches serving as incubator leaders; experts who taught teams human-centered design principles and supported teams as they learned to use this methodology (“process coaches”); and medical and business students from the organizing university (“student fellows”). Other supporters included researcher-observers, a managed care organization (“insurer”), the incubator’s private funder, and the incubator’s advisory board. The incubator organized didactic and shared learning sessions, presentation workshops, and opportunities for teams to present their work to internal and external parties. Each team, with input from clinic leadership, selected the problem/opportunity to focus on, e.g., funding and spreading a behavioral health add-on service, preventing unnecessary emergency room visits, and increasing patients’ portal use. Perhaps because of the depth of resources, all teams completed the program and made progress on stated goals. The teams and supporters worked via a mix of in-person, online, and hybrid meetings. The incubator offered similar support across the two years with the exception of an in-person launch event in the second year.

Data Collection

This study was part of a larger project that gave us access to recordings of the teams’ work meetings, meetings with supporters, and archival data, such as teams’ application materials to the incubator and presentations about their work throughout the teams’ innovation work. We conducted interviews of team members and supporters that were informed by our observations of the teams’ meetings, incubator leaders’ meetings, didactic sessions, and presentations.

Over 24 months we conducted 85 interviews: 50 with 35 team members and 35 with 17 supporters. The supporter interviewees included four content coaches, three process coaches, six student fellows, and three employees with the insurer (CEO, data analyst, project manager), one incubator project manager, and one funder. We had the opportunity to interview some team members and supporters multiple times (e.g., at the beginning, middle, or end of the year’s program) depending on the individual’s availability. All interviews were conducted on Zoom. During the interviews, we sought to understand the kinds of support that were provided and how teams and supporters experienced the support provided. We developed our interview questions based on our observations of team meetings (see Appendix for a sample interview guide).

Analysis

Our analysis involved four stages. In the first stage, we wrote memos and engaged in extensive discussions about the six teams (anonymized to Teams Coral, Emerald, Maroon, Orange, Teal, and Beige) and their supporters (anonymized using Roman numerals) based on our observation of team meetings and presentations, as well as our interviews with the teams and supporters. We were struck by the different types of support the teams received—some of it expected and some not. This led us to review the literature to better understand what is known about supporting multidisciplinary frontline teams engaging in innovation work. In the second stage, we tried to better understand the support provided by each role and the incubator programming. This involved compiling a preliminary list of support practices by supporter role, which included going back to the data to create descriptions of each practice. For example, we saw in meetings, and noted during interviews, that process coaches imparted skills related to the human-centered design process and teamwork (“facilitate skill building”), role modeled interpersonal skills to elicit participation and manage disagreements (“help with team dynamics”), and validated team members’ strengths and efforts (“affirm”). Those formed the support practices for process coaches. We also noted that the funder gave inspirational talks to teams (“motivate teams”) and financed the incubator to defray the cost of team members’ time (“provide financial support”). Those formed the support practices for the funder. These preliminary support practices by supporters became our initial codebook. In the third stage, we used the initial codebook to first code four interview transcripts from interviews with a process coach, content coach, student fellow, and clinic team member. Through this process, we refined the codebook and standardized our coding work. Next, we divided the remaining transcripts among four authors to code using the codebook. All authors met weekly to discuss the coding progress and questions that arose while coding, which helped us to further refine and iterate on the codebook. During coding, we saw that some practices were thematically similar and enacted by multiple roles, so we grouped the categories into different sets. While we saw these practices occurred throughout the study period, some practices were more foundational than others. In the fourth stage, we further explored the responsive and dynamic nature of the support practices that supporters provided in response to the various barriers that teams encountered in their innovation work. We organized the support practices that responded to specific barriers. For example, we observed limited relationships among team members of some teams (as members came from different roles, departments, and positions) that hindered the team’s work, and supporters would help foster positive team dynamics in response. We also observed limited relationships between some teams and their organization’s senior leaders, and in response, supporters would emphasize the importance of obtaining buy-in from key parties or cultivate buy-in on behalf of the team. We noted that while teams viewed these practices as beneficial, they did not always uniformly view them that way. We indicated the shortcomings of the practices and of how they were implemented.

Results

The teams we observed varied in their experience with innovation work. Some teams had members with no innovation experience, while other teams had one or more members with innovation experience. Even among those with innovation experience, however, members differed in which methodologies they were familiar with (e.g., human-centered design, IHI toolkits, lean methodologies). Teams also varied in their access to senior leaders, external partners, and other key parties. Some teams included senior leaders or middle managers, while others were composed entirely of frontline employees with limited experience in partnering with or influencing others. Finally, most teams struggled with how to fit innovation work into the broader context of their day-to-day work.

Figure 1 depicts an idealized framework of support for frontline-led innovation teams. We characterize the sets of support that can be enacted for teams with varying levels of limited innovation experience, limited relationships, or limited contextual awareness. We depict the types of support that helped innovation teams push forward new programs and processes, including Ensure Foundational Support, which encompassed financial and data support; Transmit Knowledge and Skills that helped teams learn how to use innovation frameworks and methodologies; Nurture Teams and Teamwork that helped teams work more effectively together; Cultivate Relationships with Decision-Makers that helped teams get the buy-in needed to carry out their work; Scaffold Project Work that ensured teams had necessary structures for innovation work; and Foster a Holistic View of Innovation Work that oriented teams to their work and context while helping to build an innovation mindset. These sets of support acted in concert to respond to teams’ needs as they faced initial barriers and ongoing challenges. We also describe when and how these support practices helped the team.

Ensure Foundational Support

Financial support defrayed the cost of the team members’ time to participate in innovation work that was added to their day-to-day work in delivering care. Process Coach III explained, “In general, it’s hard for frontline people to frame the future while also doing the current. They just don’t have time or capacity carved out to do it.” The financial support also served to provide legitimacy for innovation work. A Team Maroon member explained, “The incubator gave us the intensity of the investment and the funding to be able to actually say this thing is a priority, that we can use clinician time and other really important staff time.”

Motivating team members’ participation entailed incubator staff and coaches onboarding team members and helping teams and their clinics perceive innovation as a crucial opportunity to address clinical or organizational issues. The Funder also played a critical role in describing his use of small, frontline innovation teams to tackle challenges in his organization and other leading companies. He said, “Whenever there’s a major problem or any major product introduction, we formed little teams. We gave them extra authority, we gave them protection from top management, we gave them protection from their day jobs, and said go away and just do this.” Together staff, coaches, and the Funder created a case for the work that these teams were selected to engage in.

Access to data and analysis was limited at every clinic, so having the insurer provide data and analysis enabled teams to measure their progress over time. A data analyst based at the insurer shared monthly reports on emergency department and acute inpatient visits with a team whose project aimed to reduce hospitalizations. A senior leader at the insurer added,

We have a growing health analytics unit that can help provide feedback on what’s working or what’s not working. But really, I think foremost it’s [the insurer] functioning as a trusted partner to the health centers, being with them and showing support and encouragement, providing feedback that we can on their performance.

Benefits and Boundaries

These foundational supports were critical to ensure that innovation teams had the resources and motivation to learn and make progress; without these, we expect team member participation to have collapsed under the weight of their day-to-day work. Yet while funding was critical to support team members’ time, all team members we observed still struggled with time constraints. They had to prioritize their clinical or administrative responsibilities during working hours and engage with innovation work during early mornings, lunch breaks, evenings, and weekends. Those who had administrative roles were able to more flexibly manage their schedule. Those who worked directly with patients became overwhelmed more quickly; it was therefore critical for their organizations to provide them with meaningful adjustments (e.g., be taken off from other projects, cross-training staff to step in for them in the clinic) even if they were unable to hire temporary replacements due to national staff shortages.

With the insurer’s data provision, while teams found this support critical to their ability to determine problem areas and evaluate their work, getting fine-grained data specific to their project was often difficult. When teams needed data that deviated from standardized report templates, preparing such data required time, effort for the analysts at the insurer, and ongoing communication between teams and the insurer, creating obstacles to data sharing. One team was able to work around this by partnering with epidemiologists from local agencies and universities.

Transmit Knowledge and Skills

This set of support practices responded to teams’ varying experience with innovation work. Supporters helped teams gain shared knowledge and skills to conduct innovation work. Table 1 describes these practices, who enacted them, and illustrative quotes.

Table 1.

Transmit Knowledge and Skills.

Supporter practices	Definition	Illustrative quote
Facilitate skill building via iterative instruction and hands-on support	Provide on going skill building—both didactic and adaptive—that meets teams where they are.	“The primary goal is to build capability, build teams, build an internalized customized process so that they can do this [innovation work] in the future . . . . We are about building skills and processes.” (Process Coach I) “I’m super excited to work on the synthesis. We’re on the synthesis part right now with [Process Coach I] and then we’ll create flow charts and operational changes for the next year and see how impactful it is.” (Team Orange member)
Share content knowledge collected for the team	Compile and present information needed to further the teams’ work and/or help them overcome barriers.	“We started out by wanting to put together something that would be helpful. Very broadly, we wanted to serve as consultants and do what the team couldn’t do and that was provide research insights. . .. I just gave a presentation two weeks ago to the whole team to describe what we found with the experiment that we did and some best practices that we put together.” (Student Fellow II) “[Content Coach II] sent me many TED talks on presenting, and I must have watched 40 of them to the point where the next time we presented, our constructive feedback giver actually said, ‘Wow! I’ve never had anyone listen to my feedback the way you all have.’” (Team Teal member)
Share content knowledge from past work	Present information needed based on supporters’ experience.	“Something I really appreciate about [Content Coach I] is his real experience in healthcare and with a lot of these issues, and so being able to bounce ideas off of someone who’s been there, done that, was extremely helpful.” (Team Emerald member) I was hoping through this project to share some of what I know about what really works and how you’d get there with systems that haven’t really been doing that very much and at the same time. (Content Coach III)

Facilitate Skill Building Team members gained skills through didactic instruction and experiential learning on innovation frameworks and methodologies. Process coaches provided training on human-centered design principles, through which teams learned to better understand their organization, collect data, and define problems before generating and prototyping ideas. Teams also learned how to organize project work and delegate tasks. Process Coach IV shared,

I remember we made three teams: somebody takes charge of patient interviews, somebody takes charge of expert internal interviews, and someone takes charge of clinician interviews . . . . I’ve been forceful about saying, ‘Here’s how to break this task up into chunks.’

Process coaches also role-modeled and engaged in ongoing work to help the teams learn skills and tools that matched where they were in the process. A Teal team member said:

[Process Coach III] is a magician. She can go in on the Miro board, move things around, take our ideas and cluster them together . . . . not something beautiful–she was very clear about that. The goal is not to make it pretty but to cluster our ideas together and data together, to produce the path ahead.

Given teams’ limited time, they appreciated hands-on support through which they learned how to use new tools for the first time. Team members commented that, while didactic instruction was helpful, it was critical to have help applying the learning to their own idiosyncratic context.

Share Content Knowledge Collected for the Team Student fellows and content coaches gathered information that team members did not have time to collect on their own. This effort included literature reviews, online searches, interviews with clinic staff, and external benchmarking. For example, a student fellow who regularly attended team meetings saw that the team wanted to explore how to improve their call center, so as a class project, he and several classmates conducted literature reviews and reached out to organizations to research how different call centers directed calls and used (or did not use) scripts. This information informed the team’s assumptions and conversations with their own call center staff. In addition, given significant state-wide changes to Medicaid, incubator leaders organized a session with subject matter experts to discuss and answer questions about policy changes and implications so that teams could better position their projects.

Share Content Knowledge from Past Work Content and process coaches, as well as incubator-sponsored programming, provided information to teams, including best practices in their project area (e.g., urgent care, hospital-clinic communication, readmission), knowledge of relevant past change efforts, and relevant frameworks used in the field. Content and process coaches provided information in real time during coaching meetings. Content Coach I shared, “I know the most exciting models in the country . . . . It might not be a bad idea for them to adopt somebody else’s idea.” A team member shared, “[Content Coach I] was very good at asking us questions, at bringing up his experiences, which are so rich in terms of working with other FQHCs and piloting these types of projects.” Adding to information provided by coaches, incubator programming hosted online talks with external experts who discussed their own projects and experiences.

Benefits and Boundaries

Teams welcomed the new skills they were learning; however, some teams embraced and applied the content knowledge that the supporters provided, while others felt that such support took time away from their project work or was not always applicable to their context. A team member highlighted this tension:

[Content Coach I] has strong opinions about our specific topic, so we’re trying to balance his opinions with some ideas we have. Staying open minded to the things that he’s saying, while also not letting some of his personal preferences sway us.

Supporters similarly felt tension between letting teams discover how they wanted to proceed and providing input. Coaches varied in their willingness to learn alongside team members– some were willing to expand their repertoire and approach to be responsive to teams and their context, while others focused on what they knew to be best practices.

Nurture Teams and Teamwork

Teams benefited from support that responded to their emotional and social difficulties (Table 2). Often, team members were new not only to one another but also to the kinds of roles represented on the team.

Table 2.

Nurture Teams and Teamwork.

Supporter practices	Definition	Illustrative quote
Affirm individuals and the team	Offer recognition and encouragement for team members’ effort and work.	“[Content Coach III’s] is a very good personality match for me and our team. We are very hard on ourselves, so having somebody who is skilled at observing and deeply encouraging is what we needed. We don’t need someone to tell us that we’re failing at; we feel that way sometimes. [Coach] is very good at bringing in his own allegory and making everyone on our team feel like people, so I feel like I have a friend, which is something that I will be grateful for for a very long time.” (Team Maroon member)
Help foster positive team dynamics	Help launch the team and enable effective team processes and culture.	[Process Coach III] really set that tone. She likes to use emojis at check-in, and so we’re going around and seeing the emoji faces of ‘Oh, your teeth are clenched,’ you know. That’s been helpful because it’s real. We’re oftentimes trying not to be negative, trying not to sound like we’re complaining, and oftentimes that restricts us in being creative and being honest.” (Team Teal member) “[Process Coach III] said ‘You don’t have to have all five [team members] meet together.’ Sometimes you can say, ‘Okay, at this meeting we’re gonna split up and do some work and come back together, or for the next 20 minute we’ll do individual work and then come together.’ I think our most productive meetings were when we had a shared screen on Zoom, and someone was making edits to the PowerPoint in real time. Otherwise we’re just talking about ideas, and then the work is still not done with the deadlines approaching.” (Team Teal member)
Provide mentorship	Provide guidance for how to engage with innovation in the context of current job and career.	[Team member] needed some help with time management . . . she felt like she was constantly drinking from a fire hose and not able to get to what she needed to. And so some of it was just me sitting down and being like, ‘How does your day usually go? What is your work composed of? Okay, it sounds like you have some stuff that comes up ad hoc or urgent and there’s some stuff that you just need heads-down time to focus on. Are there times in your day that you can block off for not dealing with the urgent stuff to be able to do the heads-down stuff? Is there stuff that you can delegate to someone else? Is there stuff that you can push back on the urgency when it comes to you?’ . . . Not that I’m a huge expert in time management. These are just things that I had started to do, that I found useful. I was trying to give her more control over her schedule. Give her that agency to think about it that way.” (Student Fellow VI)

Affirm Individuals and the Team Coaches and student fellows validated team members’ strengths and efforts by encouraging teams and individuals and celebrating their accomplishments throughout the process. Supporters helped team members not only gain and practice skills, but also feel comfortable using these new skills, taking on new roles and work, and working through obstacles. A Team Teal member recalled a presentation she was nervous to give and was grateful that two student fellows assigned to her team attended. She said, “During one of the presentations, I remember [student fellow and student fellow], I could see their faces in an ocean of Zoom, and they were just going like this [making a heart symbol with their hands]. So supportive.”

Help Foster Positive Team Dynamics Process coaches, student fellows, and content coaches helped create norms and role model interpersonal skills to elicit participation, manage disagreements, align team members around the work, and adopt a team mindset. A Team Orange member described a student fellow’s help with team dynamics:

She had a way of doing our check-ins, making sure that everybody got to speak their piece, and that was a game changer . . . . Everybody had their 5- to 15-minutes, and she kept everybody accountable for what our responsibilities were for the next meeting. After that it was just a wildfire, but in a good way. It just blossomed, exploded.

A Team Maroon member shared her experience with a process coach,

[Process Coach III] is very skilled at observing team dynamics and navigating around hitches on the road. That’s something that we relied very hard on her for. Our team needed somebody to say, I see this dynamic is happening, don’t get discouraged by it, this happens all the time, just keep going. Or I see this dynamic is happening, I have an idea, let’s try this.

Provide Mentorship Content coaches provided advice, resources, and perspectives on team members’ work, networks, and career aspirations. A student fellow unexpectedly also took on mentoring responsibilities when meeting with team members one-on-one, helping them navigate and realize the career benefits of undertaking unfamiliar tasks, such as public speaking and negotiating time between innovation and day-to-day work.

Benefits and Boundaries

Team members expressed appreciation for affirmation and troubleshooting team dynamics, especially in the face of uncertainty and tasks that diverged significantly from day-to-day work. A Team Maroon member said that two members from her team would have

side conversations with [Process Coach III] who helped work through some of the difficult team dynamics. She gave us suggestions about how to make that shift when things were not working well for us to make progress with our oversized team.

It was, however, difficult to balance time in meetings for interpersonal check-ins with work time. Some teams found a balance by using relationships to further the work, while others began to resent time spent on small talk and exercises that they felt could have been better spent on project work.

Team members described a sense of relief in knowing that they were individually supported when they had questions or concerns about the project, their organization, or careers. A Team Teal member described gratitude at being pushed to take on new work and encouraged to develop skills:

[Content Coach II] made it clear from the beginning: he wants to be more of a coach than a leader, so that set the stage for more mentorship and coaching rather than the way I wanted to initially go to him, to just give me instructions . . . Our team was apologetic in our PowerPoint presentation [describes how work shifted]. [Content Coach II] came in and basically said, ‘Own it and present where you are.’ We are evolving. This work is evolving as it should. That really helped us move along, and that’s where we absolutely need mentorship.

Cultivate Relationships With Decision-Makers

Many team members had no previous experience creating change with peers and leaders Table 3 shows the support practices addressing this challenge. Supporters helped team members build and expand their relationships and influence–sometimes by borrowing legitimacy from a high-status coach.

Table 3.

Cultivate Relationships With Decision-Makers.

Supporter practices	Definition	Illustrative quote
Emphasize the importance of managing key parties	Help the team engage with and secure buy in from power holders while also creating space for independent exploratory work.	“[Content Coach III] suggested getting input from our providers for the condition- appropriate timing–not just for clinical input, but to get their endorsement. That was really smart. I’ve used that for other things because not everyone is going to agree on everything. I often think that providers have the sense that it’s coming from above, right? Or you’re just telling me what to do. But when you say I worked in collaboration with some of your colleagues and they agreed, that’s very powerful.” (Team Orange member) “We carved out a special place to say, ‘OK, all right. Thank you, advisors. We will connect back with you at the right time.’ In a way, there were voices not being heard that we carved into a core group to say, ‘All right, let’s really elevate those voices more.’ And I think that actually helped quite a bit.” (Process Coach III)
Cultivate organizational buy-in	Use own legitimacy to advocate for the team’s work.	“I met with the CEO, the CMO, and the chief IT person. I communicated and had lunch once or twice with the CMO during the course of the year. The IT person, I took him out for a hamburger, and I made sure the team invited him to two or three of the meetings. He’s very capable, very involved.” (Content Coach II)

Emphasize the Importance of Obtaining Buy-in of Key Parties Content and process coaches provided training on how to be more organizationally savvy with internal leaders and key parties. The coaches prompted the team to reflect on how and when to engage with which party. The incubator programming encouraged clinic leaders to attend teams’ midpoint and final presentations. During this time, teams discussed progress and received feedback and cultivated organizational leaders’ buy-in. Process coaches helped teams figure out when to create distance from key parties, to create temporary space away from leaders and colleagues to learn and experiment on their own.

Directly Foster Organizational Buy-in Content coaches advocated on behalf of the team to garner support from key parties (e.g., senior leaders, incubator staff, insurer) who needed to provide authority, information, or resources to teams. For example, coaches worked to ensure that clinic leadership was aware that teams needed extended periods of time to do project work, different or additional people on the team, access to organizational background information, or even words of recognition and encouragement from leadership. Content Coach III explained,

The worry I had was that they [senior leaders] had signed up this group but weren’t visibly supporting them . . . I wanted to have a point to meet with both [the clinic CEO and COO], and it turns out that they’re both quite supportive. They hadn’t been in the loop getting all of the feedback as we went. We changed that, and I was impressed that they were supporting the process and they were not going to pull the rug out from underneath the team.

Benefits and Boundaries

Obtaining organizational buy-in was widely recognized as critical by supporters and team members alike; however, actually engendering organizational buy-in was difficult for time-constrained teams. For teams who had regular direct access to organizational leaders, some content coaches chose to let the team navigate those relationships on their own. Other coaches stepped in to ask for more resources, though teams did not expect or desire such support, creating tensions between team members and supporters. Teams composed almost entirely of frontline staff expressed gratitude when content coaches stepped in to advocate on their behalf. However, supporters’ advocacy on behalf of these teams also highlighted the team’s own distance to leaders and their own inability to garner leader support.

Scaffold Project Work

Even as teams learned new skills and cultivated organizational buy-in, they struggled to manage their day-to-day workload along with innovation project work. Supporters helped scaffold teams’ work by providing structured processes and connections that helped teams make progress (see Table 4).

Table 4.

Scaffold Project Work.

Supporter practices	Definition	Illustrative quote
Ensure project management support	Role model and/or assign person to provide support managing the team’s work and time.	“Having someone since the very beginning to keep us focused on the project—it was amazing. Nowadays, even if they are not in the meetings, we know what to do.” (Team Teal member) “There was a little bit of lack of clarity on what needed to happen next, and who was doing what. So I volunteered to provide a bit of project management support, setting meeting agendas, taking meeting minutes, setting action items. The main point of that structure, what I was trying to achieve, was making it clear to everyone where we are at, where we are going, who is responsible for what, to use the meeting time more effectively to connect people who don’t get a chance to meet.” (Student Fellow VI)
Structure opportunities for sharing experience and learning	Provide times for teams to learn from each other’s experience and expertise.	“Collegiality was probably the most fruitful of having those interactions [meetings with other teams]. Just being able to commiserate [with other clinic teams]. Like, ‘you have problems with this?’ . . . I don’t know if we learned necessarily from their specific projects, but certainly during design camp, you see it in the room, a lot of interaction and collegiality and commiseration and stuff like that.” (Team Coral member)

Ensure Project Management Support Coaches, student fellows, and a project manager provided by the insurer helped teams develop meeting agendas and to-do lists, take meeting notes, and facilitate meetings in a structured way. An unexpected source of project management was a student fellow who planned to work on a literature review but found that “would be less helpful just given where the team was and the hurdles they were facing.” She instead created and taught the team to use project management structures. Other supporters like content coaches did not take on a project manager role. Instead, they helped teams realize that they should appoint a team member to take charge of managing the team’s work. The project manager provided by the insurer ensured that inter-team meetings had agendas and that teams had templates to use when presenting.

Structure Opportunities for Sharing Experience and Learning The incubator organized time and space for teams to share their experience, learning, and progress with other teams. Team members learned about the approaches and tools other teams used, commiserated over shared difficulties of innovation work, and were held accountable by seeing others’ work that motivated teams to “keep up” with those who were further ahead. Team members expressed that meeting with other teams helped them feel more in community and less alone in their struggles. In addition, incubator programming organized sessions during which content and process coaches, the incubator advisory board (composed of senior leaders in the region), and external experts could collectively serve as a sounding board, provide feedback, and help teams determine next steps.

Benefits and Boundaries

While most team member-managers had project management skills, they often struggled to simultaneously contribute as a team member and as a project manager. The project manager provided by the insurer was able to manage incubator-level timelines, but unable to provide hands-on project management support to each team. Those who worked as frontline providers generally lacked project management skills and did not perceive the need to have a project manager on their team, so supporters were critically important in helping them fill this role.

Team members unanimously agreed that having dedicated inter-team time and space for sharing learnings and troubleshooting was helpful and would have appreciated even more time with other teams. However, teams also struggled to tell incubator leaders that they preferred to meet directly with other teams without the coaches.

Some team members became disheartened upon receiving candid and sharp feedback on their presentation from an external expert. These team members felt “sideswiped” after operating in a space of safety. Coaches acknowledged the need for the different types of feedback from different experts but realized the delivery was ineffective, as these experts were not bought into the culture of the incubator. Teams’ perceived need to respond to the external expert’s feedback shifted time and effort away from innovation work and reduced psychological safety. It was difficult for supporters to know how to calibrate feedback so that it was useful but not distracting to the teams’ work.

Foster a Holistic View of Innovation Work

A significant difficulty that resulted from clinics having limited experience with innovation work or experience only with top-down innovation work was that frontline team members generally lacked context of how their project fit within the clinic, within their community, and with industry- and regulation-level changes Table 5 shows the support practices addressing this difficulty. One team did not know about prior organizational efforts to address a similar goal or how their work fit with organizational priorities. Some team members and their managers were not aware of the time and emotional ups and downs inherent in the innovation process. Many frontline team members had limited relationships with others who might have done similar work or had relevant expertise.

Table 5.

Foster Holistic View of Innovation Work.

Supporter practices	Definition	Illustrative quote
Contextualize project work	Help the team situate themselves in the broader context.	“It was helpful for [Content Coach II] to help us more in the macro and to think strategically about how we want to be successful.” (Team Coral member) “We consider ourselves pretty patient centered and we have zero mechanism for really soliciting patient feedback or patient input into any of our program designs . . . . This was sort of an eye opener.” (Team Emerald member)
Contextualize innovation process	Help the team understand the inherently iterative and dynamic innovation process.	“We often draw this thing called the mood meter . . . We take this as the emotional experience of someone doing a transformation project. You start off thinking, ‘Where are we going?’ and you go out and gather information. And it’s always illuminating and exciting and motivating; you see things you’ve never seen before, and you think this is just going to be terrific and the greatest time. Then you realize just how hard it’s going to be, and your initial 20 ideas go down to one idea, which the executive hates. You start thinking, ‘Well, maybe we have trouble here,’ and then you’re able to pull it all together . . . . Not only the team goes through that, but also the coaches go through that. We don’t know where we’re going either when we’re here . . .I’ve been doing this 20 years, I still feel that way. But having done it for 20 years, I know with certainty that I’m going to end up here. I feel very confident about that. That’s impossible for someone going through this for the first time, to experience that emotional truth when they’re in that deep moment, and they don’t feel the certainty that it’s going to be okay. So you have to be there to not just project confidence but also have the empathy that this is difficult for them.” (Process Coach I)
Enable reframing	Provide reflection space to allow for perspectives that might have not been considered.	“Look, you’re not reinventing the wheel. What you are inventing is the experience that you want your patients and your staff to have. Then you go and shop for solutions. With that experience blueprint, you can go into these conversations. You have a point of view, and you can make demands. If you sit and just listen to what the vendor has to sell you, then you can only say yes to whatever they offer to you, which is a very different negotiation standpoint than being like, ‘Look, this is the experience I want to create. How can you help us do that?’ I feel like [Team Beige member] really got that point. . . . So often we’ve seen that it’s whatever leadership wants or however good the sales techniques are of the vendors . . . . So that was a nice reframing.” (Process Coach II) “Now I’m working with some MA leads on organizing design thinking sessions . . . to understand from the MA and other provider perspective . . . to get their perspective on how exactly this could look in practice. That was something that I’ve been excited about, in terms of getting bottom-up perspective . . . . I gave a presentation to the [team] about it and what we found from the literature and the interviews was a mix of things that told us that MAs were not necessarily fully on board . . . that led to conversations with the leadership team that culminated in ‘OK, how can we figure out how to bring MA and frontline provider voices to the table in a meaningful way.’” (Student Fellow I)
Connect to external resources	Introduce the team to people and projects that help push their work forward.	“[Content coach II] has been invaluable. He’s been super supportive, making connections with people with his depth of knowledge of people in the community, in the medical world, in the legislative world—just hooking us up with people that we need to hook up with to make this work and to grow the ideas that we were trying to incubate.” (Team Coral member) “We were informed about a model by [Content Coach I] who connected us with one of his alumni, who told us about the model. That conversation was very generative. Being connected with alumni of the program and understanding what this looks like much later would be something I would urge to be brought in early because that was super fruitful. You don’t have to reinvent the wheel, the wheel is out there; it’s just that you’re not using it. You can iterate on it if you know it exists.” (Team Maroon member)

Contextualize Project Work Content coaches and incubator programming helped teams learn more about how their work fit into the health care industry, policy space, community, and their own organizations’ history and priorities. Specifically, supporters brought to the teams’ attention how their work might be impacted by impending policy changes and the barriers they might face due to changes in payment, reimbursement, and technology.

Contextualize Innovation Process The process coaches helped teams understand the innovation process and mindset, particularly the iterative, uncertain, ambiguous, and time-intensive nature of innovating. This was particularly important for teams and members with no or limited experience with innovation work since they struggled with uncertainty and unsuccessful prototypes. A Team Orange member shared that she learned from the team’s content coach “how to think about an improvement project, how to look ahead to plan ahead to what we should be looking for.” A Team Emerald member said knowing what to expect helped:

Coming up to our first set of pilots, everyone is very much prepared for them to be a disaster and then regroup and see what we learn and try something else, and just keep tweaking it until it feels like we are making progress.

Enable Reframing When teams encountered barriers, process and content coaches prompted team members to reflect on their approach and make adjustments to their work and their mindset. Coaches nudged team members to take time to think about whether their existing projects were going to make the intended impact or whether they needed to pivot their work. As research-observers, the authors conducted semi-structured interviews that prompted team members to reflect on and discuss their goals, values, and experiences with the incubator. A process coach shared the importance of building team members’ mindset for innovation work over time: “You have to create sort of a transformation in mindsets, and that doesn’t happen in a day or two.” Coaches helped teams consider various alternatives rather than having them simply do more work. A Team Teal member described how a process coach suggested, “Let’s step back and look at everything. She was instrumental for us in learning how to use a different way of thinking.” A Team Emerald member described how their coach “provided a mirror for us to look back at our organization and ourselves and our role, while at the same time being extremely positive, like he’s just a very positive force.” Student fellows were particularly important for helping teams consider new ways of approaching their work. A Team Teal member described,

In gathering research, . . . they come in with lots of new ideas and new systems. One health center has just a QR code on badges and so with patients in front of them, they could scan it with a phone, and there’s your patient education material, rather than let me try and find a printer that works and walk away.

Connect to External Resources Content and process coaches, student fellows, and incubator programming facilitated introductions and connections with content experts, organizations doing similar work, and strategic partners. Supporters drew on their network, and expanded their own network when needed, to help link teams to resources. A Team Beige member shared, “[Content coach] has been around here forever so it seems like he knows everyone. He was very helpful.”

Benefits and Boundaries

By knowing what to expect and being supported through failure, teams were able to focus on learning and trying again. Team members shared that gaining a big-picture perspective and additional support on contextualizing their innovation work and process were valuable. A Team Teal member explained, “This [experience] has helped us to go outside our little borders to learn what’s out there.” However, given their limited time, some team members struggled to absorb the contextual information, engage in reflective activities, and follow up with their new connections, especially if this was their first time engaging in this work. We observed that supporters had to be cognizant of how much individuals and teams could absorb at one time.

Discussion

Dynamic and multisource support efforts across roles and programming are critical for the success of frontline innovation teams. The innovation teams we observed were motivated and hard working. Yet, they were also time-constrained, and many members lacked substantive experience with innovation, with each other and their organizational leaders, and with balancing forward-looking change work with day-to-day work. A “net of support” that included a range of supporters and support practices were critical for teams as they learned and engaged with innovation work.

Our study builds on prior work that underscores the importance of considering the context under which innovation teams operate and the barriers that teams may face at the onset (Rushton et al., 2023). Our findings suggest that supporters needed to be able to read the room and determine when to encourage team building and frame the innovation work in a way that team members did not feel like it was a waste of time. Supporters also needed to determine when to provide advice and when to let the teams work through an issue; when to advocate for teams with organizational leadership and when to step back and let teams make those asks themselves; and when to jump in and help with project management and when to help the team develop the roles and skills to do so on their own. Supporters, however, varied in their ability to read the room and adapt (Satterstrom et al., 2019). For example, coaches who could adjust the pace and provision of content knowledge were viewed as helpful because teams needed this support at select key periods rather than at a steady pace. More work is needed on how to sensitize supporters to understand how to effectively calibrate their support and know when to step back or step up their support.

Our findings illustrate benefits of multisource support of innovation teams. A wide range of supporters helped the six teams make progress on their innovation projects by providing an array of instructions, resources, and encouragements. Such support helped to build not only the team’s capacity to carry out innovation work, but also the relationships that teams needed to be successful. At the same time, however, the support, particularly when it involves different groups of supporters, is necessarily dynamic, messy, and interactive. As more supporters work to enable and empower innovation teams, collaboration and alignment become increasingly difficult and important. More research is needed as collaborative coaching of teams is novel and requires more careful attention, especially in light of differences in team and supporter expertise, experience, and power dynamics.

The multisource nature of support demonstrated the critical role of both content and process coaches, and also identified significant roles unexpectedly played by other supporters. In particular, the student fellows differed widely in their impact, ranging from being seen as not very helpful to being lauded as the most essential support. The wide-ranging degree of helpfulness among student fellows could be attributed to their having the least defined roles. Moreover, having the least experience in these settings (i.e., healthcare clinics) allowed them to contribute fresh perspectives and tailor their support based on observations. While experts are commonly associated with providing helpful support, novices like the student fellows (Zhang et al., 2023) may be untapped high-potential resources for health care innovation teams. Their contributions warrant further study.

Limitations

Our study draws on one incubator, with FQHCs in one state undergoing many regulatory changes. While this context may have influenced the teams’ motivation to engage in innovation—possibly limiting the generalizability of our findings—it also provided a naturalistic setting to observe how teams carry out innovation work. Moreover, the six teams we studied exhibited many heterogeneities—in terms of prior experience with innovation, team size, roles and positions represented on the team, and complexities and scope of the projects they undertook—enhancing the robustness and potential relevance of our findings across diverse organizational contexts.

Practical Implications

Our study has implications for practitioners, especially those who support healthcare teams engaged in innovation work or organize, train, or sponsor supporters. While a wide range of supporters who can role model and provide hands-on support may not be readily available for most clinics, recognizing the benefits of various support practices can help innovation teams overcome their day-to-day barriers and create successful changes to their clinics. Many organizations have recognized the need for a trained QI specialist, and there may be opportunities to tap other roles in the organization. Our findings suggest that teams benefit from having supporters who can help contextualize project work within the larger health care system; help teams navigate organizational goals, policies, insurance plans, financial expectations, and other knowledge that frontline teams might not otherwise by privy to; or bridge frontline teams with organizational functions like information technology or external key parties like the insurer and the local public health department. Moreover, our findings suggest that information and expertise could arise from unexpected sources. Student fellows, who had the least defined roles and most limited work experience, were able to bring fresh perspectives and tailor their support to what they observed.

Teams that do not have the time for innovation work may feel burdened by support that they cannot afford to benefit from and may create resentment and additional stress. At a time when clinics are struggling to attract and retain frontline staff, there is recognition that giving people the opportunity to learn new skills, improve their workplace and patient care, and have a say in organizationally meaningful decisions can alleviate burnout (Jung et al., 2024; Kerrissey et al., 2022). Yet, if this work and associated support add to employees’ day-to-day work, requiring them to work nights and weekends, it may end up exacerbating burnout. This study was conducted in FQHCs, where, as in other resource-strapped organizations, financial support was needed to create the bandwidth necessary for innovation teams comprising frontline clinicians and staff.

Reflecting the work of Hackman (2002) and Ancona and Bresman (2007), team support structures should be designed with multifaceted goals, so that supporters are able and understand how to help teams with project work, help teams develop their ability to work together, and help team members develop individual skills. Yet balance helps. On one hand, too much support may feel frustrating if it impedes progress on innovation work and limits teams to working within existing models and methodologies. On the other hand, too much focus on getting work done and too little support can hinder building capacity, requiring longer ongoing support, and teams may default to working in a hierarchy instead of as a team and spend their time “rediscovering the wheel.”

Appendix

We created slightly different interview guides by role and time period. Below is a sample guide from our interview with content coaches toward the end of the study period. All other interview guides are available upon request.

Introduction

• What are the characteristics to describe this team to someone who is not familiar with this team?

Teams

• Did your team assign roles and responsibilities? (e.g., project or team related roles, like project management, note taking, content expert, communicating with senior managers)

  • ○ If so, how were they assigned?

  • ○ How did it work out? (e.g., did people do the jobs assigned?)

• What are some norms for your team? (e.g., things you always do like checking in with each other at the start of the meeting)

  • ○ To what extent have these norms played a role in pushing your project/work forward?

  • ○ How have these norms changed over time, if at all?

• What does leadership look like in your team?

  • ○ Leadership: Centralized? Decentralized? Someone who speaks up most? We’re just trying to understand what leadership looks like in your context/situation.

• How would you describe the team members’ relationship with each other? Did those relationships change or evolve over time?

• How do you think each member of the team changed or evolved or grew into their role on the team/project?

  • ○ Are there specific skills that members learned individually or collectively throughout the year?

  • ○ [Prompt for individual members of the team]

Transitioning people in and out [for people who have been on the team or left the team]

• Can you describe any changes that were made to the core team membership?

• Why did these changes happen?

  • ○ How much input did you have to making these changes?

• How do you/people on the team bring up / raise different perspectives or disagreements?

• How do you work through them?

  • ○ Describe a conflict or disagreement that your team had to work through recently.

• How does your team make decisions?

Meeting

• What do you think about how the teams’ meetings went?

  • ○ Has this changed over time? How has this change helped or hinder your team to make progress on your work?

  • ○ How are the meetings organized? How structured are the meetings? Is it an effective structure?

  • ○ How much do you accomplish?

• Can you describe the work that you do between meetings?

Student Involvement

• What was it like to have [NAME OF THE STUDENT] on your team?

• Were they helpful to the team?

  • ○ What, if anything, did they help with? (e.g., coordinating, project management, literature review, etc.)

    • ▖ What skills did they bring?

    • ▖ What perspective(s) did they bring?

  • ○ How could they have been more helpful?

• Did you meet with the student outside of team meetings?

  • ○ If yes, what was that like?

  • ○ Was it helpful?

• What, if anything, have you learned from working with students?

  • ○ Some things that students could see/observe, offer different perspective from their point of view, etc.

Stakeholders

• Who are your project stakeholders/partners?

  • ○ Inside your organization?

  • ○ Outside of your organization?

• How did you interact with those stakeholders as a coach?

• How have these stakeholders helped to push your project forward? Or hold it back?

Project Work

• How much progress do you feel the team has made toward solving their clinic’s initial problem (identified in the application and elaborated on during design camp)?

• Has the focus of your project shifted since the start? If so, how?

  • ○ [something about how the team builds the momentum for work?]

• What ideas have been implemented? What ideas are being piloted?

• Is there anything else your team has accomplished this year?

• What has helped and/or hindered accomplishing this work?

• Is there any part of the project that you feel you had ownership over (shared/sole)?

Uses of Data

• How has the team used data to show the impact of the team’s work?

• What are things that have improved that might be difficult to capture in the data?

Coaches’ Relationship With Team

• How would you describe your role as a coach for/on this team?

• How would you describe your interactions with people on the team / team as a whole? Have your interactions changed over time?

• How would you describe your relationships with people on the team? Have these relationships changed since you started working together?

• How do you think your role as a coach helped or hindered the team (e.g., building team relationships, getting project work done, facilitating meetings, etc.)?

Incubator as a Whole

• How do you think the incubator program went as a whole this past year (year 2)?

• What, if anything, have you learned from this work?